Trans-catheter mitral valve-in-valve replacement in a patient on venoarterial extracorporeal membrane oxygenation: a case report.

Background: Bioprosthetic mitral valves on average have a median durability between 8 and 10 years. After the failure of a bioprosthetic valve, surgical replacement is often indicated. However, the options for those patients at high or prohibitive surgical risks are limited. Here, we describe a case of a successful trans-catheter mitral valve-in-valve (TMViV) replacement on venoarterial extracorporeal membrane oxygenation (VA-ECMO). Case summary: We describe a case of a 39-year-old female with a history notable for systemic lupus erythematosus, severe pulmonary arterial hypertension (now mixed pre and post) thought to be secondary to prior substance use, and infective endocarditis complicated by severe mitral stenosis status post-bioprosthetic mitral valve replacement who presented with symptoms of acute hypoxic respiratory failure secondary to severe bioprosthetic mitral valve stenosis. The patient had a prolonged hospital course complicated by a pulseless electrical activity arrest, (continuous renal replacement therapy) for acute renal failure, and hypertonic saline due to cerebral oedema. Due to her significant co-morbidities and haemodynamic instability with acute kidney injury and recent neurologic insult, the patient was thought not to be a good surgical candidate. However, given her young age and overall improved neurologic status, it was thought the patient could benefit from a TMViV with bi-ventricular support given her right- and left-sided heart failure and was placed on VA-ECMO in anticipation of a TMViV procedure for circulatory support. The patient underwent a successful TMViV replacement using a trans-septal approach with a 26 mm SAPIEN 3 valve and atrial septal defect closure with a 14 mm Amplatzer device on hospital Day 12. The patient was successfully de-cannulated from VA-ECMO on hospital Day 13. The patient had a prolonged hospital course but eventually had renal recovery and tracheostomy de-cannulation. A trans-thoracic echocardiogram prior to discharge was notable for a well-functioning valve and normal ejection fraction. The patient was discharged to a nursing home for further rehabilitation. Discussion: The gold standard for bioprosthetic mitral valve stenosis is surgical replacement of the valve. However, the options for those at high or prohibitive surgical risk are lacking. Recent studies have demonstrated TMViV is a safe alternative to surgical mitral valve redo cases in high-risk patients. To our knowledge, there are limited data on trans-catheter valve placement while on VA-ECMO. Successful implantation in our patient suggests that TMViV in a stenotic bioprosthesis is feasible in very high-risk patients with the use of VA-ECMO to support haemodynamics.

Racial/Ethnic Disparities in Outcomes After Percutaneous Coronary Intervention.

Asian American/Pacific Islanders (AAPIs) and Hispanics are growing minority United States populations, but are poorly represented in the cardiovascular literature. This study examines guideline adherence and outcomes in AAPIs and Hispanics compared with non-Hispanic Whites (NHWs) in a quaternary care center after inpatient percutaneous coronary intervention (PCI). The primary end points were inpatient post-PCI bleed, heart failure, cardiogenic shock, and all-cause mortality, whereas the secondary end point was the prescription rate of post-PCI guideline-directed medical therapy including aspirin, statins, P2Y12 receptor blockers, and cardiopulmonary rehabilitation. Intergroup differences were assessed through analysis of variance or two-way chi-square tests, and the association of race with binary outcomes was examined through logistic regression with NHW as the reference group. Compared with NHW, AAPIs, and Hispanics had higher odds of diabetes mellitus, and AAPIs had higher odds of hypertension and being on dialysis. Hispanics had higher odds of post-PCI mortality versus NHW, both in acute coronary syndrome (odds ratio [OR] 2.04, p = 0.03) and elective PCI (OR 2.51, p = 0.04). AAPI also trended toward higher mortality than NHW in both categories. AAPIs were found to have higher odds of statin prescription (OR 1.91, p = 0.04). Hispanics had lower odds of ticagrelor prescription versus NHW (OR 0.65, p = 0.04), and AAPIs trended toward such. No differences were found for cardiopulmonary rehabilitation prescriptions in groups. This study suggests that despite quality improvement efforts, disparities remain in postprocedural outcomes in minority groups in comparison with NHW.

Transcatheter Aortic Valve Replacement Guided by Preprocedural Simulation of Fluoroscopic Location of the Membranous Septum.

We show the virtual simulation of the fluoroscopic location of the membranous septum using preprocedural cardiac computed tomographic data sets. Recognizing the risk distance before the procedure can help individualize implantation strategy to reduce the risk of atrioventricular conduction axis damage during transcatheter aortic valve replacement. (Level of Difficulty: Advanced.).

Effects of leaflet curvature and thickness on the crimping stresses in transcatheter heart valve.

With the current advances and expertise in biomedical device technologies, transcatheter heart valves (THVs) have been drawing significant attention. Various studies have been carried out on their durability and damage by dynamic loading in operational conditions. However, very few numerical investigations have been conducted to understand the effects of leaflet curvature and thickness on the crimping stresses which arise during the surgical preparation processes. In order to contribute to the current state of the art, a full heart valve model was presented, the leaflet curvature and thickness of which were then parameterized so as to understand the stress generation as a result of the crimping procedure during the surgical preparations. The results show that the existence of stresses is inevitable during the crimping procedure, which is a reduction factor for valve durability. Especially, stresses on the leaflets at the suture sites connected with the skirt were deduced to be critical and may result in leaflet ruptures after THV implantation.

Transcatheter Aortic Valve Replacement for Severe Aortic Valve Stenosis: Do Patients Experience Better Quality of Life Regardless of Gradient?

BACKGROUND: Aortic valve replacement improves survival for patients with low-gradient aortic valve stenosis, but there is a paucity of data on postoperative quality of life for this population. METHODS: In a single-center retrospective analysis of 304 patients with severe aortic valve stenosis who underwent transcatheter aortic valve replacement, patients were divided into 4 groups based on mean pressure gradient, left ventricular ejection fraction, and stroke volume index. Using the Kansas City Cardiomyopathy Questionnaire-12, quality of life was assessed immediately before and 1 month after transcatheter aortic valve replacement. RESULTS: Most patients in the low-flow, low-gradient group were men; this group had higher relative rates of cardiovascular disease and type 2 diabetes than the paradoxical low-flow, low-gradient group; the normal-flow, low-gradient group; and the high-gradient group. All-cause mortality did not differ significantly among the groups at 1 month after surgery, and all groups experienced a significant improvement in quality-of-life scores after surgery. The mean improvement was 27 points in the low-flow, low-gradient group, 25 points in the paradoxical low-flow, low-gradient group, 30 points in the normal-flow, low-gradient group, and 30 points in the high-gradient group (all P < .001). CONCLUSION: Quality of life improves significantly across all subgroups of aortic valve stenosis after trans-catheter aortic valve replacement, regardless of flow characteristics or aortic valve gradients.

Sex Differences in Outcomes of Percutaneous Pulmonary Artery Thrombectomy in Patients With Pulmonary Embolism.

BACKGROUND: The sex differences in use, safety outcomes, and health-care resource use of patients with pulmonary embolism (PE) undergoing percutaneous pulmonary artery thrombectomy are not well characterized. RESEARCH QUESTION: What are the sex differences in outcomes for patients diagnosed with PE who undergo percutaneous pulmonary artery thrombectomy? STUDY DESIGN AND METHODS: This retrospective cross-sectional study used national inpatient claims data to identify patients in the United States with a discharge diagnosis of PE who underwent percutaneous thrombectomy between January 2016 and December 2018. We evaluated the demographics, comorbidities, safety outcomes (in-hospital mortality), and health-care resource use (discharge to home, length of stay, and hospital charges) of patients with PE undergoing percutaneous thrombectomy. RESULTS: Among 1,128,904 patients with a diagnosis of PE between 2016 and 2018, 5,160 patients (0.5%) underwent percutaneous pulmonary artery thrombectomy. When compared with male patients, female patients showed higher procedural bleeding (16.9% vs 11.2%; P < .05), required more blood transfusions (11.9% vs 5.7%; P < .05), and experienced more vascular complications (5.0% vs 1.5%; P < .05). Women experienced higher in-hospital mortality (16.9% vs 9.3%; adjusted OR, 1.9; 95% CI, 1.2-3.0; P = .003) when compared with men. Although length of stay and hospital charges were similar to those of men, women were less likely to be discharged home after surviving hospitalization (47.9% vs 60.3%; adjusted OR, 0.7; 95% CI, 0.50-0.99; P = .04). INTERPRETATION: In this large nationwide cohort, women with PE who underwent percutaneous thrombectomy showed higher morbidity and in-hospital mortality compared with men.

Impact of frailty on mortality and quality of life in patients with a history of cancer undergoing transcatheter aortic valve replacement.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) is increasingly offered for aortic stenosis (AS) treatment in patients with a history of cancer. The impact of frailty on outcomes in this specific patient population is not well described. HYPOTHESIS: Frailty is associated with mortality and poorer quality of life (QOL) outcomes in patients undergoing TAVR with a history of cancer. METHODS: This retrospective single center cohort study included AS patients who underwent TAVR from August 1, 2012 to May 15, 2020. Frailty was measured using serum albumin, hemoglobin, gait speed, functional dependence, and cognitive impairment. The primary outcome was a composite of all-cause mortality and QOL at 1 year. A poor primary outcome was defined as either all-cause mortality, Kansas City Cardiomyopathy Questionnaire overall summary (KCCQ-OS) score <45 or a KCCQ-OS score decline of ≥10 points from baseline. Regression analysis was used to determine the impact of frailty on the primary outcome. RESULTS: The study population was stratified into active/recent cancer (n = 107), remote cancer (n = 85), and non-cancer (n = 448). Univariate analysis of each cohort showed that frailty was associated with the primary outcome only in the non-cancer cohort (p = .004). Multivariate analysis showed that cancer history was not associated with a poor primary outcome, whereas frailty was (1.7 odds ratio, 95% confidence interval [CI]: 1.1-2.8; p = .028). CONCLUSIONS: Frailty is associated with mortality and poor QOL in the overall and non-cancer cohorts. Further investigation is warranted to understand frailty's effect on the cancer population. Frailty should be heavily considered during TAVR evaluation.

Single versus double Perclose techniques for vascular closure during transfemoral transcatheter aortic valve replacement.

INTRODUCTION: The preferred approach for transcatheter aortic valve replacement (TAVR) is transfemoral. There has been widespread adoption of the Perclose ProglideTM device for vascular closure. Typically, two devices are deployed before upsizing the access sheath in the "preclose technique." Prior investigations have compared the use of a single device versus double device technique, but none have shown significant clinical benefit to either approach. METHODS: Five hundred and six patients underwent transfemoral TAVR (TF-TAVR) with single or double Perclose devices for vascular closure from July 2015 to February 2020. A retrospective review was conducted, and propensity-matched analyses were used to account for differences in baseline characteristics. RESULTS: In the matched analysis, there were 251 patients in the single Perclose group and 238 in the double. There was a statistically significant improvement in overall procedural success using the single closure device (94.6% vs. 88.5%, p = 0.009) This was defined as intraprocedural hemostatic control, lack of contrast extravasation, arterial dissection, occlusion, or stenosis >50% in the final crossover angiogram, as well as unimpaired limb perfusion without claudication throughout the index hospitalization. There was also a significant improvement in arterial dissection rates (0.6% vs. 4.6%, p = 0.004), stenosis >50% (1.3% vs. 4.4%, p = 0.028), and Valve Academic Research Consortium major vascular complications (1.8% vs. 4.9%, p = 0.038). CONCLUSION: A single Perclose device is a safe means of vascular closure during TF-TAVR and may have important clinical benefits compared to the commonly used two-device technique.

Fractional Flow Reserve in End-Stage Liver Disease.

Fractional flow reserve (FFR) determines the functional significance of epicardial stenoses assuming negligible venous pressure (Pv) and microvascular resistance. However, these assumptions may be invalid in end-stage liver disease (ESLD) because of fluctuating Pv and vasodilation. Accordingly, all patients with ESLD who underwent right-sided cardiac catheterization and coronary angiography with FFR as part of their orthotopic liver transplantation evaluation between 2013 and 2018 were included in the present study. Resting mean distal coronary pressure (Pd)/mean aortic pressure (Pa), FFR, and Pv were measured. FFR accounting for Pv (FFR - Pv) was defined as (Pd - Pv)/(Pa - Pv). The hyperemic effect of adenosine was defined as resting Pd/Pa - FFR. The primary outcome was all-cause mortality at 1 year. In 42 patients with ESLD, 49 stenoses were interrogated by FFR (90% were <70% diameter stenosis). Overall, the median model for ESLD score was 16.5 (10.8 to 25.5), FFR was 0.87 (0.81 to 0.94), Pv was 8 mm Hg (4 to 14), FFR-Pv was 0.86 (0.80 to 0.94), and hyperemic effect of adenosine was 0.06 (0.02 to 0.08). FFR-Pv led to the reclassification of 1 stenosis as functionally significant. There was no significant correlation between the median model for ESLD score and the hyperemic effect of adenosine (R = 0.10). At 1 year, 13 patients had died (92% noncardiac in etiology), and patients with FFR ≤0.80 had significantly higher all-cause mortality (73% vs 17%, p = 0.001. In conclusion, in patients with ESLD who underwent orthotopic liver transplantation evaluation, Pv has minimal impact on FFR, and the hyperemic effect of adenosine is preserved. Furthermore, even in patients with the predominantly angiographically-intermediate disease, FFR ≤0.80 was an independent predictor of all-cause mortality.

Change in Invasively Measured Mean Pulmonary Artery Pressure After Transcatheter Mitral Valve Repair Is Associated With Heart Failure Readmission.

BACKGROUND: Pre-existing pulmonary hypertension is associated with poor outcomes after transcatheter mitral valve repair (TMVr) for mitral regurgitation (MR). However, the impact of an immediate change in mean pulmonary artery pressure (ΔmPAP) following TMVr on outcomes is unknown. METHODS: Patients who underwent TMVr from December 2015 to February 18, 2020 at our institution for symptomatic 3-4+ MR and who had invasive hemodynamics measured immediately pre- and post-TMVR were included. Multivariate Cox regression analysis was performed to examine the association of ΔmPAP (post-TMVr - pre-TMVr mPAP) with the primary endpoint of heart failure (HF) readmission at 1 year. Secondary endpoints included all-cause mortality and the composite endpoint of HF readmission or all-cause mortality at 1 year. RESULTS: Among 55 patients, 55% were men, mean age was 72 ± 14.2 years, and mean ΔmPAP was -1.4 ± 8.2 mm Hg. Overall, HF readmission occurred in 14 (25%), death in 10 (18%), and the composite endpoint in 20 (36%) patients. In multivariable analyses, higher ΔmPAP was significantly associated with HF readmission (hazard ratio (HR) = 1.10, 95% confidence interval (CI): 1.00 - 1.21; P = 0.04). ΔmPAP was not associated with death (HR = 1.04, 95% CI: 0.96 - 1.14; P = 0.33), though there was a numerical but statistically non-significant trend towards the composite endpoint (HR = 1.06, 95% CI: 1.00 - 1.13; P = 0.06) driven by HF readmission. CONCLUSION: Higher ΔmPAP immediately following TMVr was associated with increased HF readmission at 1 year. Larger prospective studies are needed to validate these data and further explore the utility of ΔmPAP as a novel hemodynamic parameter to predict post-TMVR outcomes.

Left main coronary artery compression in pulmonary hypertension.

Extrinsic compression of the left main coronary artery (LMCA) by a dilated pulmonary artery (PA) in the setting of pulmonary arterial hypertension (PAH) is an increasingly recognized disease entity. LMCA compression has been associated with angina, arrhythmia, heart failure, and sudden cardiac death in patients with PAH. Recent studies suggest that at least 6% of patients with PAH have significant LMCA compression. Screening for LMCA compression can be achieved with computed coronary tomography angiography, with a particular emphasis on assessment of PA size and any associated downward displacement and reduced takeoff angle of the LMCA. Indeed, evidence of a dilated PA (>40 mm), a reduced LMCA takeoff angle (<60°), and/or LMCA stenosis on CCTA imaging should prompt further diagnostic evaluation. Coronary angiography in conjunction with intravascular imaging has proven effective in diagnosing LMCA compression and guiding subsequent treatment. While optimal medical therapy and surgical correction remain in the clinician's arsenal, percutaneous coronary intervention has emerged as an effective treatment for LMCA compression. Given the prevalence of LMCA compression, its associated morbidity, and mortality, and the wide array of successful treatment strategies, maintaining a high degree of suspicion for this condition, and understanding the potential treatment strategies is critical.

Paravalvular Leak Assessment: Challenges in Assessing Severity and Interventional Approaches.

PURPOSE OF REVIEW: With increasing use of prosthetic valves to treat degenerative valvular heart disease (VHD) in an aging population, the incidence and adverse consequences of paravalvular leaks (PVL) are better recognized. The present work aims to provide a cohesive review of the available literature in order to better guide the evaluation and management of PVL. RECENT FINDINGS: Despite gains in operator experience and design innovation, significant PVL remains a significant complication that may present with congestive heart failure and/or hemolytic anemia. To date, clear consensus or guidelines on the evaluation and management of PVL remain lacking. Although the evolution of transcatheter valve therapies has had a tremendous impact on the management of patients with VHD, the limitations and complications of such techniques, including PVL, present further challenges. Incidence of PVL, graded as moderate or greater, ranges from 4 to 7.4% in surgical and transcatheter valve replacements, respectively. Improved imaging modalities and the advent of novel surgical and percutaneous therapies have undoubtedly yielded a better understanding of PVL including its anatomical location, mechanism, severity, and treatment options. Echocardiography, used in conjunction with cardiac computed tomography and cardiac magnetic resonance, provides essential details for diagnosis and management of PVL. Transcatheter intervention has become a favored approach in lieu of surgical intervention in select patients after previous surgical or percutaneous valve replacement. PVL treatment with vascular plugs, balloon post-dilation, and the valve-in-valve methods have shown technical success with promising clinical outcomes in appropriately selected patients.

Angiotensin Converting Enzyme Inhibitor and Angiotensin II Receptor Blocker Use Among Outpatients Diagnosed With COVID-19.

Coronavirus disease 2019 (COVID-19) is a viral pandemic precipitated by the severe acute respiratory syndrome coronavirus 2. Since previous reports suggested that viral entry into cells may involve angiotensin converting enzyme 2, there has been growing concern that angiotensin converting enzyme inhibitor (ACEI) and angiotensin II receptor blocker (ARB) use may exacerbate the disease severity. In this retrospective, single-center US study of adult patients diagnosed with COVID-19, we evaluated the association of ACEI/ARB use with hospital admission. Secondary outcomes included: ICU admission, mechanical ventilation, length of hospital stay, use of inotropes, and all-cause mortality. Propensity score matching was performed to account for potential confounders. Among 590 unmatched patients diagnosed with COVID-19, 78 patients were receiving ACEI/ARB (median age 63 years and 59.7% male) and 512 patients were non-users (median age 42 years and 47.1% male). In the propensity matched population, multivariate logistic regression analysis adjusting for age, gender and comorbidities demonstrated that ACEI/ARB use was not associated with hospital admission (OR 1.2, 95%CI 0.5 to 2.7, p = 0.652). CAD and CKD/end stage renal disease [ESRD] remained independently associated with admission to hospital. All-cause mortality, ICU stay, need for ventilation, and inotrope use was not significantly different between the 2 study groups. In conclusion, among patients who were diagnosed with COVID-19, ACEI/ARB use was not associated with increased risk of hospital admission.

Combined Transcatheter Tricuspid and Pulmonary Valve Replacement.

BACKGROUND: For patients with combined tricuspid and pulmonary valve disease, operative intervention carries high mortality risk. Published reports of combined transcatheter tricuspid and pulmonary valve replacement have been limited to single cases. METHODS: A retrospective chart review was performed including all patients undergoing combined transcatheter tricuspid and pulmonary valve replacement at the Ahmanson/UCLA Adult Congenital Heart Disease Center. RESULTS: Combined transcatheter tricuspid and pulmonary valve replacement was undertaken in five adult patients (median age: 46 years; range: 24-64 years). Three had congenital heart disease and two had carcinoid syndrome. Four patients had previous surgical tricuspid valve replacement and one had a surgical incomplete annuloplasty ring. Four patients had previous surgical pulmonary valve replacement and one had a right ventricle-to-pulmonary artery homograft conduit. Two patients underwent Medtronic Melody valve implantation in both tricuspid and pulmonary positions and three underwent Edwards Sapien S3 implantation in both tricuspid and pulmonary positions. Valve implantation was successful in all. Follow-up ranged from 0.9 to 3.0 years. One patient underwent redo transcatheter tricuspid valve replacement 12 months after the first transcatheter intervention for progressive regurgitation of a Melody valve. This patient died 2.5 years after combined valve placement of complications from refractory heart failure. The remaining patients were alive and free of valve reintervention at follow-up. CONCLUSIONS: Combined transcatheter tricuspid and pulmonary valve replacement can be performed successfully, with an acceptable complication rate. This strategy is a feasible option for appropriately selected patients.

Single Center Trends in Acute Coronary Syndrome Volume and Outcomes During the COVID-19 Pandemic.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has greatly affected healthcare delivery across the world. In this report, we aim to further characterize the changes in cardiac catheterization at our institution, specifically in the setting of acute coronary syndrome (ACS). METHODS: We performed a retrospective analysis of patients undergoing cardiac catheterization between December 23, 2019 and April 12, 2020 at our institution. All patients with cardiac catheterizations for ACS, ST-elevation myocardial infarction (STEMI) activation, and out-of-hospital cardiac arrest (OHCA) were analyzed. Cardiac catheterization volume, as well as clinical and procedural characteristics of patients undergoing cardiac catheterization, was compared before and during the COVID-19 pandemic. RESULTS: Patients presenting with ACS and OHCA were similar in terms of demographics and comorbidities during both time periods. The mean monthly volume for ACS cases dropped by 26% during the pandemic, which was consistent among both unstable angina/non-ST-elevation myocardial infarction (UA/NSTEMI) and STEMI cases. OHCA volume decreased significantly as well (five cases per month before to zero cases during the pandemic, P = 0.01). Among patients with STEMI, initial markers of cardiac injury, door-to-balloon time, and all-cause mortality were similar in both time periods. CONCLUSIONS: With the start of the COVID-19 pandemic, there was a reduction in cardiac catheterization volume across the spectrum of ACS at our institution, which was consistent with reports from other centers across the globe. Patients with STEMI during the initial phase of the COVID-19 pandemic did not seem to have delays in presentation or significant differences in all-cause mortality at our institution.

Incidence, Predictors, and Outcomes of New-Onset Left Ventricular Systolic Dysfunction After Orthotopic Liver Transplantation.

BACKGROUND: Adverse cardiovascular events after liver transplantation (LT) are relatively common and are a significant source of early mortality. Although new-onset systolic dysfunction after LT is a reported phenomenon, there is little data regarding its incidence, risk factors, and outcomes. METHODS AND RESULTS: This single-center retrospective study included all adult patients from January 2002 to March 2015 with deceased-donor LT and available preoperative transthoracic echocardiograms (TTEs). In total, 1,760 patients were included in the study, 602 (34.2%) of whom had a postoperative TTE. The primary end point was development of new-onset cardiomyopathy, defined as a new left ventricular ejection fraction (LVEF) of <40% within 180days of transplant. Sixty-nine (11.4%) of the patients who received post-LT TTE had a reduction in LVEF to <40% within 6 months. Clinical parameters of donor and recipient did not show significant impact on development of post-LT LV systolic dysfunction (LVSD). Presence of wall motion abnormalities (P = .004) on preoperative TTE was predictive of development of post-LT LVSD. These patients did not have longer hospitalizations, but they had worse survival. CONCLUSIONS: Post-LT LV systolic dysfunction occurs at higher rates than previously suspected and may develop more frequently in patients with underlying cardiac structural abnormalities, which appear to adversely affect post-LT survival.

The CatLet score: a new coronary angiographic scoring tool accommodating the variable coronary anatomy for the first time.

BACKGROUND: The SYNTAX score for decision makings or outcome predictions in coronary artery disease does not account for the variations in the coronary anatomy, which is a clear fallacy for patients with less typical anatomy than suggested by the SYNTAX score. The current study aimed to derive a new coronary angiographic scoring system accommodating the variability in the coronary anatomy. METHODS: The 17-myocardial segment model and laws of competitive blood supply and flow conservation were utilized to derive this new scoring system. RESULTS: We obtained 6 types of RCA dominance, 3 types of diagonal size and 3 types of left anterior descending artery (LAD) length, which together resulted in a total of 54 patterns of coronary artery circulation to account for the variability in the coronary anatomy among individuals. A Coronary Artery Tree description and Lesion EvaluaTion (CatLet) angiographic scoring system has been designed based on the above-mentioned reclassification scheme (htpp://www.catletscore.com, IE browser is required to run this calculator). CONCLUSIONS: This new CatLet angiographic scoring system accommodated the variability in the coronary anatomy and standardized the collection of the coronary angiographic data, which could facilitate the comparison and exchange of these data between different catheter labs. Its utility for predicting the clinical outcomes and standardizing the angiographic data collection will be investigated in a series of clinical trials enrolling "all-comers" with coronary artery disease (CAD).

Vascular Complications in the Sapien 3 Era: Continued Role of Transapical Approach to Transcatheter Aortic Valve Replacement.

With the introduction of the latest generation Sapien 3 (S3) transcatheter aortic valve, there has been a reduction in the usage of transapical (TA) approach for transcatheter aortic valve replacements in many centers. However, despite the smaller sheath size and the more streamlined delivery system, vascular complications continue to occur, especially in patients with peripheral vascular disease. Thus, our institution has maintained a stringent TA protocol aiming to prevent these complications. We hypothesize that this protocol has helped to reduce vascular complications and improve outcomes at our institution even in the S3 era. All transcatheter aortic valve replacement procedures done at our institution were considered for analysis. Patients were grouped according to whether their procedure was done before (Pre-S3 era) or after (S3 era) the introduction of the S3 valve, as well as whether they underwent a TA or a transfemoral (TF) approach. A femoral artery intraluminal diameter of <7.5 mm in the Pre-S3 era and <5.5 mm in the S3 era with circumferential calcifications triggered TA approach consideration. Vascular complications included vascular perforation, dissection, flow-limiting stenosis, unplanned vascular surgery, significant postprocedural bleeding, hematoma at the access site, and retroperitoneal bleed. The Welch t test of unequal variance and chi-squared test were used as appropriate. An alpha of <0.05 was considered significant. A total of 275 patients were included in the analysis (121 Pre-S3 era and 154 S3 era). The TA approach was utilized in 45% in the Pre-S3 era vs 15% in the S3 era (P < 0.001). Within the S3 era, 131 underwent the TF approach compared with 23 who underwent the TA approach. TA and TF patients were similar in all preoperative characteristics except hypertension. Mortality was significantly lower in the S3 era (0% vs 4% in the pre-S3 era, P = 0.02). Overall rates of vascular complications were similar between the Pre-S3 and the S3 eras (16% vs 14%, P = 0.63). Overall adverse outcomes were similar between the TA and the TF groups. TA patients saw significantly longer intensive care unit stay and total hospital stay. Our results show that despite a smaller sheath size, vascular complications continue at a similar rate into the S3 era. This occurred in the setting of an ongoing aggressive TA utilization in select patients, specifically those with peripheral vascular disease. Maintaining this approach is likely a large contributor to both our current success and reduced mortality.

Myocardial functional changes in transfemoral versus transapical aortic valve replacement.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) has greatly expanded the treatment options available for patients with severe aortic stenosis at high surgical risk. MATERIALS AND METHODS: We compared changes in myocardial function in TAVR with a transfemoral (TF) versus a transapical (TA) approach at a major tertiary hospital from 2012-2016. Traditional echocardiographic measures of cardiac structure and function were tracked, alongside the use of two-dimensional speckle tracking echocardiography to measure myocardial strain and strain rates. RESULTS: For the entire cohort with complete data at all time points (n = 42), between the pre-TAVR baseline (mean: 20.1 d) and the post-TAVR 1-mo follow-up (mean: 32.7 d), global longitudinal strain significantly increased (from -15.6% to -18.2%, P < 0.001). When comparing the TF (n = 31) and TA (n = 11) groups, TA patients showed persistently impaired apical longitudinal strain at the 1-mo follow-up (-15.9% versus -22.3%, P < 0.05). In terms of clinical outcomes, both groups (n = 131 for TF, n = 53 for TA) were similar in terms of 30-d mortality, readmission rate, and risk of post-TAVR acute kidney injury. However, TA patients experienced significantly longer length of hospitalization (7.58 versus 3.92 d, P = 0.02), intensive care unit hours (105.4 versus 47.1 h, P = 0.02), and were at a greater risk of long-term (>72 h) intensive care unit stay (45% versus 25%, P = 0.01). CONCLUSIONS: Patients undergoing TA-TAVR exhibit impaired apical longitudinal strain, although global myocardial function is similar to TF-TAVR otherwise. Myocardial strain measured by two-dimensional speckle tracking echocardiography appears to be a sensitive method to detect subtle cardiac remodeling after TAVR.

Ferumoxytol-enhanced MR Angiography for Vascular Access Mapping before Transcatheter Aortic Valve Replacement in Patients with Renal Impairment: A Step Toward Patient-specific Care.

Purpose To assess the technical feasibility of the use of ferumoxytol-enhanced (FE) magnetic resonance (MR) angiography for vascular mapping before transcatheter aortic valve replacement in patients with renal impairment. Materials and Methods This was an institutional review board-approved and HIPAA-compliant study. FE MR angiography was performed at 3.0 T or 1.5 T. Unenhanced computed tomographic (CT) images were used to overlay vascular calcification on FE MR angiographic images as composite fused three-dimensional data. Image quality of the subclavian and aortoiliofemoral arterial tree and confidence in the assessment of calcification were evaluated by using a four-point scale (4 = excellent vascular definition or strong confidence). Signal intensity nonuniformity as reflected by the heterogeneity index (ratio between the mean standard deviation of luminal signal intensity and the mean luminal signal intensity), signal-to-noise ratio, and consistency of luminal diameter measurements were quantified. Findings at FE MR angiography were compared with pelvic angiograms. Results Twenty-six patients underwent FE MR angiography without adverse events. A total of 286 named vascular segments were scored. The image quality score was 4 for 99% (283 of 286) of the segments (κ = 0.9). There was moderate to strong confidence in the ability to assess vascular calcific morphology in all studies with complementary unenhanced CT. The steady-state luminal heterogeneity index was low, and signal-to-noise ratio was high. Interobserver luminal measurements were reliable (intraclass correlation coefficient, 0.98; 95% confidence interval: 0.98, 0.99). FE MR angiographic findings were consistent with correlative pelvic angiograms in all 16 patients for whom the latter were available. Conclusion In patients with renal impairment undergoing transcatheter aortic valve replacement, FE MR angiography is technically feasible and offers reliable vascular mapping without exposure to iodine- or gadolinium-based contrast agents. Thus, the total cumulative dose of iodine-based contrast material is minimized and the risk of acute nephropathy is reduced. © RSNA, 2017 Online supplemental material is available for this article.